Current outcomes following upper and lower extremity arterial trauma from the National Trauma Data Bank.

OBJECTIVE: The modern treatments of trauma have changed in recent years. We aim to evaluate the factors associated with limb salvage and mortality after extremity arterial trauma, especially with respect to the type of conduit used in revascularization. METHODS: The National Trauma Data Bank was queried to identify patients with upper and lower extremity (UE and LE) arterial injuries between 2016 and 2020. The patients were stratified by the types of arterial repair. The primary outcome was in-hospital mortality. RESULTS: 8780 patients were found with 5054 (58%) UE and 3726 (42%) LE injuries. Eighty-three percent were men, and the mean age was 34 ± 15 years. Penetrating mechanism was the predominant mode of injury in both UEs and LEs (73% and 67%, respectively) with a mean injury severity score of 14 ± 8. For UEs, the majority underwent primary repair (67%, P < .001), whereas the remainder received either a bypass (20%) or interposition graft (12%). However, LEs were more likely to receive a bypass (52%, P < .00001) than primary repair or interposition graft (34% and 14%, respectively). Compared with the extremely low rates of amputation and mortality among UE patients (2% for both), LE injuries were more likely to result in both amputation (10%, P < .001) and death (6%, P < .001). Notably, compared with primary repair, the use of a prosthetic conduit was associated with a 6.7-fold increase in the risk of amputation in UE and a 2.4-fold increase in LE (P < .0001 for both). Synthetic bypasses were associated with a nearly 3-fold increase in return to the operating room (OR) in UE bypasses (P < .05) and a 2.4-fold increase in return to the OR in LE bypasses (P < .0001). CONCLUSIONS: In recent years, most extremity vascular trauma was due to penetrating injury with a substantial burden of morbidity and mortality. However, both limb salvage rates and survival rates have remained high. Overall, LE injuries more often led to amputation and mortality than UE injuries. The most frequently used bypass conduit was vein, which was associated with less risk of unplanned return to the OR and limb loss, corroborating current practice guidelines for extremity arterial trauma.

Five-year outcomes of fenestrated and branched endovascular repair of complex aortic aneurysms based on aneurysm extent.

OBJECTIVE: The aim of this study was to evaluate the 5-year outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of complex aortic aneurysms stratified by the aneurysm extent. METHODS: Patients with the diagnosis of complex aortic aneurysm, who underwent F/BEVAR at a single center were included in this study and retrospectively analyzed. The cohort was divided according to the aneurysm extent, comparing group 1 (types I-III thoracoabdominal aneurysms [TAAAs]), group 2 (type IV TAAAs), and group 3 (juxtarenal [JRAAs], pararenal [PRAAs], or paravisceral [PVAAs] aortic aneurysms). The primary endpoints were 30-day and 5-year survival. The secondary endpoints were technical success, occurrence of spinal cord ischemia, primary patency of the visceral arteries, freedom from target vessel instability, and secondary interventions. RESULTS: Of 436 patients who underwent F/BEVAR between July 2012 and May 2023, 131 presented with types I to III TAAAs, 69 with type IV TAAAs, and 236 with JRAAs, PRAAs, or PVAAs. All cases were treated under a physician-sponsored investigational device exemption protocol with a patient-specific company-manufactured or off-the-shelf device. Group 1 had significantly younger patients than group 2 or 3 respectively (69.6 ± 8.7 vs 72.4 ± 7.1 vs 73.2 ± 7.3 years; P < .001) and had a higher percentage of females (50.4% vs 21.7% vs 17.8%; P < .001). Prior history of aortic dissection was significantly more common among patients in group 1 (26% vs 1.4% vs 0.9%; P < .001), and mean aneurysm diameter was larger in group 1 (64.5 vs 60.7 vs 63.2 mm; P = .033). Comorbidities were similar between groups, except for coronary artery disease (P < .001) and tobacco use (P = .003), which were less prevalent in group 1. Technical success was similar in the three groups (98.5% vs 98.6% vs 98.7%; P > .99). The 30-day mortality was 4.5%, 1.4%, and 0.4%, in groups 1, 2, and 3, respectively, and was significantly higher in group 1 when compared with group 3 (P = .01). The incidence of spinal cord ischemia was significantly higher in group 1 compared with group 3 (5.3% vs 4.3% vs 0.4%; P = .004). The 5-year survival was significantly higher in group 3 when compared with group 1 (P = .01). Freedom from secondary intervention was significantly higher in group 3 when compared with group 1 (P = .003). At 5 years, there was no significant difference in freedom from target vessel instability between groups or primary patency in the 1652 target vessels examined. CONCLUSIONS: Larger aneurysm extent was associated with lower 5-year survival, higher 30-day mortality, incidence of secondary interventions, and spinal cord ischemia. The prevalence of secondary interventions in all groups makes meticulous follow-up paramount in patients with complex aortic aneurysm treated with F/BEVAR.

Trends and Outcomes in Management of Thoracic Aortic Injury in Children, Adolescent, and Mature Pediatric Patients Using Data from the National Trauma Data Bank.

BACKGROUND: Thoracic aortic injury (TAI) is rare in the pediatric population. Thoracic endovascular aortic repair (TEVAR) is the recommended standard of care for treatment in the adult population given its association with lower rates of mortality and morbidity than traditional open repairs for treatment of TAI. However, there are unique anatomic challenges in treating pediatric patients with TEVAR which may impact the outcomes and pediatric guidelines. We aimed to compare current management trends and outcomes between different pediatric age groups using data from the National Trauma Data Bank (NTDB). METHODS: We analyzed the NTDB from 2007 to 2019 using International Classification of Diseases (ICD)-9 and -10 codes to identify patients with a TAI. We excluded patients older than 21 years and any patients who died in the emergency department. The pediatric patients were stratified by age group: children (1-11 years), adolescent (12-17 years), and mature (18-21 years) patients. Patient characteristics compared included injury mechanism and severity, TAI intervention, and outcomes between the 3 groups using bivariate analysis (analysis of variance for parametric and Kruskal-Wallis for nonparametric variables). These characteristics and outcomes were also compared by TAI intervention and injury mechanism. ICD-9 and -10 procedural codes were used to identify patients who underwent TEVAR, open aortic repair (OAR), or both. The modified Poisson regression was performed with relative risk (RR) to evaluate our primary outcome measure-mortality during the trauma admission. RESULTS: A total of 2,431 pediatric TAI were identified in the NTDB that met the inclusion criteria. This included 134 children (5.5%), 733 adolescent (30.2%), and 1,564 mature (64.3%) patients. Children had significantly lower median Injury Severity Scores (34.1) than the adolescent (38) or mature population (36.1) (P = 0.001). The mechanism of injury differed between age groups. Children had higher rates of blunt trauma (90.3% children, 89.6% adolescent, and 86.8% mature patients) and mature patients had higher rates of penetrating trauma (6% children, 10.1% adolescent, and 12.5% mature patients) (P < 0.001). TAI management also differed significantly between pediatric age groups. Mature patients had significantly higher rates of TEVAR (3% children, 25.2% adolescent, and 29.2% mature patients) and children were most likely to be treated with nonoperative management (NOM) (94% children, 67.9% adolescent, and 64.8% mature patients) (P < 0.001). Patients who were treated with TEVAR were discharge home most frequently (31.8% NOM, 54.1% TEVAR, 44.3% OAR, 22.2% both TEVAR and OAR). Upon modified Poisson regression analysis, patient age was not associated with an increased risk of in-hospital mortality. Intervention with TEVAR (RR: 0.22, 95% CI: 0.15-0.33, P < 0.001) and OAR (RR: 0.58, 95% CI: 0.36-0.93, P = 0.024) were associated with a lower risk of mortality than NOM. CONCLUSIONS: TAI is less prevalent in children compared to adults. TEVAR for TAI is associated with lower risk of in-hospital mortality compared to both NOM and OAR without differences between pediatric subgroups. Further studies should be completed to determine the most appropriate management guidelines.

Higher body mass index is associated with reinterventions and lower maturation rates after upper extremity arteriovenous access creation.

OBJECTIVE: A patient's body mass index (BMI) can affect both perioperative and postoperative outcomes across all surgical specialties. Given that obesity and end-stage renal disease are growing in prevalence, we aimed to evaluate the association between BMI and outcomes of upper extremity arteriovenous (AV) access creation. METHODS: A retrospective single-institution review was conducted for AV access creations from 2014 to 2018. Patient demographics, comorbidities, and AV access details were recorded. BMI groups were defined as normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-39.9 kg/m2), and morbidly obese (>40 kg/m2). Perioperative complications and long-term outcomes including access maturation (defined as access being used for hemodialysis or the surgeon's judgment that access was ready for use in patients not yet on hemodialysis), occlusion, and reintervention were evaluated. RESULTS: A total of 611 upper extremity AV access creations were performed on patients who were normal weight (29.6%), overweight (31.3%), obese (29.6%), and morbidly obese (9.5%). Access type included brachiocephalic (43.2%), brachiobasilic (25.5%), and radiocephalic (14.2%) fistulas and AV grafts (14.2%). Median age was 60.9 years, and 59.6% were male. Univariable analysis showed no difference between BMI groups for perioperative steal, hematoma, home discharge, or 30-day primary patency. Freedom from reintervention at 2 years on Kaplan-Meier analysis differed by BMI (44.5% ± 4.6% normal weight, 29% ± 3.8% overweight, 39.8% ± 4.3% obese, 34.7% ± 8% morbidly obese; P = .041). There was no difference in 2-year freedom from new access creation or survival. AV access maturity within 180 days differed between BMI groups (74.3% normal weight, 66% overweight, 65.7% obese, 46.6% morbidly obese; P < .001). On multivariable analysis, failure to mature within 180 days was associated with overweight (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.14-3.29; P = .002), obese (OR, 2.12; 95% CI, 1.19-3.47; P = .009), and morbidly obese (OR, 3.68; 95% CI, 1.85-7.3; P < .001) relative to normal weight BMI. AV access reintervention was associated with overweight (hazard ratio [HR], 1.83; 95% CI, 1.34-2.5), obese (HR, 1.56; 95% CI, 1.12-2.16), and morbidly obese (HR, 1.69; 95% CI, 1.1-2.58; P = .02) relative to normal weight BMI. BMI was not independently associated with long-term readmission or survival. CONCLUSIONS: Obesity is associated with higher rates of AV access failure to mature and reintervention. Surgeons performing access creation on obese patients must consider this for planning and setting expectations. Weight loss assistance may need to be incorporated into treatment algorithms.

Factors associated with a tunneled dialysis catheter in place at initial arteriovenous access creation.

OBJECTIVE: Arteriovenous (AV) access is the preferred hemodialysis modality to avoid the complications associated with tunneled dialysis catheters (TDCs). Despite efforts to create timely AV access, many patients still initiate hemodialysis through TDCs. Our goal was to determine the patient factors associated with having a TDC present at initial AV access creation and how this affects survival. METHODS: We performed a single-center, retrospective review of all patients who had undergone initial AV fistula creation from 2014 to 2019. Patients with previous peritoneal or AV access were excluded. Univariable and multivariable analyses were used to identify associations with a TDC present at initial AV access creation and patient survival. RESULTS: Of 509 patients who had undergone initial AV access creation, a TDC was present in 280 (55%). The mean patient age was 59.7 ± 14.1 years. The access types were brachiocephalic (47.2%), brachiobasilic (22.4%), radiocephalic (15.5%), and prosthetic (12.6%). The patients with a TDC compared with those without a TDC were less likely to be obese (68.9% vs 54.2%), more likely to be homeless (10.4% vs 4.8%), and more likely to be an inpatient (44.6% vs 18.8%). They were less likely to have seen a primary care physician within 1 year preoperatively (54.3% vs 88.6%) and a nephrologist within 3 months preoperatively (39.3% vs 93%; P < .05 for all). On multivariable analysis, the presence of a TDC at initial AV access creation was associated with no nephrology visit within 3 months preoperatively (odds ratio [OR], 25; 95% confidence interval [CI], 12.5-50; P < .001), homeless status (OR, 2.6; 95% CI, 1.1-6.2; P = .03), and the absence of obesity (OR, 1.8; 95% CI, 1.1-2.9; P = .02). The 1-year survival was similar for patients with (95%) and without (94.8%) a TDC (P = .36) as confirmed by multivariable analysis (hazard ratio, 1.2; 95% CI, 0.65-2.1; P = .63). CONCLUSIONS: The absence of a preoperative nephrology visit, homeless status, and the absence of obesity were associated with a TDC present at initial AV access creation. However, the presence of a TDC did not appear to confer changes in short-term survival. Targeted improvements in high-risk populations such as increasing the frequency of preoperative subspecialty evaluation might be warranted to reduce TDC placement before AV access creation at urban safety-net hospitals.

The Association of the Day of the Week with Outcomes of Infrainguinal Lower Extremity Bypass.

BACKGROUND: The day of the week (DOW) for performing procedures and operations has been shown to affect clinical and resource utilization outcomes. Limited published data are available on vascular surgery operations. Our primary objective was to assess outcomes by DOW for infrainguinal lower extremity bypass (LEB) performed for claudication or rest pain. The secondary objective was to assess outcomes by DOW for LEBs performed for tissue loss. METHODS: The Vascular Quality Initiative was queried from 2003 to 2018 for all elective index infrainguinal LEBs performed for claudication or rest pain. Cases performed for acute limb ischemia as well as concomitant peripheral vascular intervention, nonelective LEBs, sequential grafts, and weekend cases were excluded. LEBs were grouped by DOW: Monday-Tuesday (early weekdays) versus Wednesday-Friday (later weekdays). Baseline data, operative details, and outcomes were collected. Univariate and multivariable analyses were performed. LEBs performed for claudication/rest pain were analyzed together while tissue loss was assessed separately. RESULTS: There were 12,084 LEBs identified-44.5% performed on Monday-Tuesday and 55.5% on Wednesday-Friday. Overall, the mean age was 65.6 years, 68.6% were male, and 82.8% were Caucasian. LEBs were performed for claudication in 57.4% of cases. An autogenous great saphenous vein was used in 58.8% of cases, whereas a prosthetic graft was used in 35.1% of cases. The most common bypass origin was the femoral artery (94.1%), and target was the popliteal artery (70.1%). Significant differences between Monday-Tuesday versus Wednesday-Friday, respectively, were mean body mass index (27.8 kg/m2 vs. 28 kg/m2), preoperative aspirin use (74.2% vs. 72.5%), continuous vein harvest technique (41.9% vs. 44%), and mean operative time (mins) (216.2 vs. 222.6) (all P < 0.05). Univariate postoperative outcomes were significantly different between Monday-Tuesday versus Wednesday-Friday, respectively, for mean length of stay (LOS) (days) (3.9 vs. 4.3), cardiac complications (myocardial infarction/dysrhythmia/congestive heart failure) (3.5% vs. 4.9%), stroke (0.3% vs. 0.6%), and respiratory complications (0.8% vs. 1.3%) (all P < 0.05). Multivariable analysis demonstrated that LEBs performed on Wednesday-Friday versus Monday-Tuesday for claudication/rest pain were independently associated with cardiac complications and prolonged LOS. There were also 8,491 LEBs performed for tissue loss which overall had similar findings to LEBs performed for claudication/rest pain such as increased LOS for LEBs performed for tissue loss on Wednesday-Friday (P < 0.001) and similar likeliness for respiratory complication, wound complication, return to the operating room, and mortality (all P > 0.05). However, LEBs performed for tissue loss on Wednesday-Friday versus Monday-Tuesday had similar cardiac complications (P > 0.05). CONCLUSIONS: Elective LEBs performed on later weekdays for claudication/rest pain were associated with cardiac complications and prolonged LOS, whereas tissue loss confirmed association with prolonged LOS. Further investigations are needed to identify whether increased resources or allocation of resources should be focused on later weekdays to optimize patient outcomes.

RETRACTED: Prevalence of unprofessional social media content among young vascular surgeons.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the authors, the Editor-in-Chief and the Senior Editor of the Journal of Vascular Surgery. This article has been retracted in accordance with the Committee on Publication Ethics (COPE) Retraction Guidelines because the authors did not have permission to use the Association of Program Directors in Vascular Surgery (APDVS) directory of program directors and trainees to conduct research. In addition, the methodology, analysis and conclusions of this article were based on published but not validated criteria, judging a series of behaviors including attire, alcohol consumption, controversial political and religious comments like abortion or gun control, in which significant conscious and unconscious biases were pervasive. The methodology was in part predicated on highly subjective assessments of professionalism based on antiquated norms and a predominantly male authorship supervised the assessments made by junior, male students and trainees. The authors did not identify biases in the methodology, i.e., judging public social media posts of women wearing bikinis on off-hours as "potentially unprofessional". The goal of professionalism in medicine is to help ensure trust among patients, colleagues and hospital staff. However, professionalism has historically been defined by and for white, heterosexual men and does not always speak to the diversity of our workforce or our patients. The Editors deeply regret the failures in the Journal's peer review process which allowed this paper to be published. The Editors and the review process failed to identify errors in the design of the study, to detect unauthorized use of the data, and to recognize the conscious and unconscious biases plaguing the methodology. For this, we express our most sincere apology.

Octogenarians and Nonoctogenarians Have Similar Outcomes after Upper Extremity Hemodialysis Access Creation.

BACKGROUND: Routine arteriovenous (AV) access creation in octogenarians is controversial. Our goal was to assess perioperative and long-term outcomes in octogenarians after undergoing upper extremity AV access to determine whether advanced age should influence AV access decision-making. METHODS: All AV access creations performed at a single institution from 2014-2018 were retrospectively reviewed. Patients were categorized as octogenarians and nonoctogenarians. Perioperative short-term outcomes were compared. RESULTS: Among 620 patients who underwent AV access creation, there were 40 octogenarians and 580 nonoctogenarians. Octogenarians were more likely to have private insurance, coronary artery disease, dementia, previous stroke, impaired ambulation, and less likely to be current smokers. There were no differences in outpatient status or tunneled dialysis catheter presence at creation. Access types were similar radiocephalic (12.5% vs. 14.3%), brachiocephalic (50% vs. 42.6%), brachiobasilic (12.5% vs. 26.2%), and grafts (25% vs. 13.8%). Univariable analysis demonstrated no differences in perioperative return to the operating room, hematoma, and patency loss. There were no differences in 90-day mortality (OR 0.46, 95% CI 0-2.5, P = 0.25), readmission (OR 1.36, 95% CI 0.67-2.76, P = 0.39), maturation (OR 0.97, 95% CI 0.46-2.01, P = 0.93), or reintervention (HR 0.9, 95% CI 0.64-1.25, P = 0.53). Octogenarians had lower two-year survival (82.5% vs. 91.9%, P < 0.001), but there was no difference in reintervention-free survival (55% vs. 47%, P = 0.47) or occlusion-free survival (25% vs. 24%, P = 0.62). CONCLUSIONS: Octogenarians and nonoctogenarians have similar outcomes after upper extremity dialysis access creation. Advanced age alone should not influence dialysis access creation.

Common femoral artery antegrade and retrograde approaches have similar access site complications.

OBJECTIVE: Ipsilateral antegrade access (AA) is an alternative access option for contralateral retrograde access (RA) in treating infrainguinal occlusive disease. Our goal was to assess whether AA is associated with higher access site complications. METHODS: The Vascular Quality Initiative database was searched from 2010 to 2017 for all infrainguinal peripheral vascular interventions. Cases without access through the common femoral artery or those with multiple accesses were excluded. Access types were classified on the basis of whether the approach was AA or RA. Propensity matching and multivariable analyses were performed to determine the effect of AA on access site complications. RESULTS: There were 45,816 access events identified, 6600 (14.4%) AA and 39,216 (85.6%) RA cases. Patients with AA were older (70.7 vs 69.1 years) and more frequently male (66.5% vs 59.1%), white (79.4% vs 74.6%), and on Medicare (58.4% vs 56%); they were more likely to have end-stage renal disease (12.1% vs 11%), and they were less frequently obese (29.3% vs 36.1%) and less likely to be currently smoking (25.5% vs 28.7%), to be diabetic (56% vs 59.8%), to have chronic obstructive pulmonary disease (20.7% vs 21.8%), and to ambulate independently (69.8% vs 72.5%; P < .05 for all). Patients with AA were more likely to have a history of a prior percutaneous vascular intervention (9.3% vs 7%), inflow bypass (6.2% vs 1.8%), and leg bypass (12.6% vs 8.9%; P < .001 for all). The AA technique was more frequently used in the setting of tissue loss (51.8% vs 45.1%) and for tibial intervention (46.3% vs 35.3%; P < .001 for both). There were no significant differences between AA and RA in overall hematoma (3% vs 2.7%; P = .21) or hematoma requiring intervention (0.4% vs 0.4%; P = .75) rates. There was no significant difference in access site occlusion or stenosis between AA and RA (0.2% vs 0.3%; P = .68). These findings were confirmed with 2:1 matching based on preoperative data and type of intervention. Multivariable analysis demonstrated that AA is not associated with increased risk of any hematoma (odds ratio [OR], 1.15; 95% confidence interval [CI], 0.98-1.35; P = .082) or hematoma requiring intervention (OR, 0.88; 95% CI, 0.57-1.35; P = .56). Multivariable analysis of the matched data confirmed these findings between AA and RA for hematoma (OR, 0.88; 95% CI, 0.73-1.06; P = .17) and hematoma requiring intervention (OR, 1.17; 95% CI, 0.7-1.95; P = .55). CONCLUSIONS: AA is safe, and it was not found to be associated with increased access site complications, such as hematoma, in the large Vascular Quality Initiative sample. This approach remains a viable alternative to traditional RA.

Emergency Department Utilization after Lower Extremity Bypass for Critical Limb Ischemia.

BACKGROUND: Patients with critical limb ischemia (CLI) utilize hospital resources at high rates. One major driver for resource utilization is emergency department (ED) visits. Our goal was to assess perioperative ED visits after lower extremity bypass (LEB) for CLI. METHODS: All patients undergoing LEB for CLI from 2008 to 2017 at our institution were analyzed. ED visits and details of the visit within 30 and 90 days of discharge from index admission were recorded. Multivariable analysis was performed to identify risk factors for any ED presentation and ED presentation without hospital admission. RESULTS: There were 317 patients identified who underwent infrainguinal LEB for CLI. Average age was 66 years, and 60.6% of patients were male. Within 30 and 90 days, 24.3% and 36.3% presented to the ED overall, and 16.7% and 26.5% of all postoperative patients had an ED presentation without hospital admission, respectively. Most common reasons for any ED visits and for ED visits without admission within 30 days were wound complications (22.1% and 20.8%), cardiac complications (16.9% and 17%), and ipsilateral leg pain (10.4% and 11.3%), respectively. Cryopreserved vein bypass (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.02-8.84, P = 0.046) and index length of stay (LOS) (OR 1.09, 95% CI 1.04-1.15, P < 0.001) predicted any 30-day ED visit. Active leg infection at the time of bypass (OR 2.35, 95% CI 1.21-4.58, P = 0.012) and index LOS (OR 1.05, 95% CI 1.004-1.09, P = 0.033) predicted 30-day ED presentation without hospital admission. Most common reasons for any ED visit and for ED visits without admission within 90 days were surgical wound complications (15.8% and 14.3%), cardiac complications (14.9% and 14.3%), and nonsurgical wounds (9.6% and 9.5%), respectively. Chronic renal insufficiency (CRI) (OR 2.73, 95% CI 1.52-4.93, P = 0.001) and index LOS (OR 1.07, 95% CI 1.01-1.12, P = 0.017) predicted any 90-day ED visit. CRI (OR 3.34, 95% CI 1.81-6.17, P = 0.001) predicted 90-day ED presentation without hospital admission. For multiple ED visits within 90 days, there were 5 patients each with 5 ED visits, 12 each with 4 ED visits, 26 each with 3 ED visits, and 47 each with 2 ED visits. CONCLUSIONS: There is a high rate of ED utilization in CLI patients after LEB. Targeting these patients with closer follow-up and improved outpatient ambulatory access could assist in decreasing the frequency of postoperative ED visits. Particular areas of targeted improvement are those patients who presented to the ED and were not admitted.

Intraoperative Heparin Use during Upper Extremity Arteriovenous Access Creation Does Not Affect Outcomes.

BACKGROUND: There are conflicting data about the effect of heparin use on perioperative outcomes during upper extremity arteriovenous (AV) access creation. Our goal was to assess the effect of the use and degree of intraoperative heparin on perioperative outcomes after AV access creation. METHODS: All upper extremity AV access cases performed at a tertiary academic medical center between 2014 and 2017 were reviewed. Patient and procedural details including intraoperative heparin use and dosing as well as protamine use were analyzed. Full heparin dose was defined as 80-100 U/kg and partial heparin dose as less than 80 U/kg. Perioperative arterial thrombosis or distal embolism, hematoma, and early loss of primary patency within 30 days were evaluated. Multivariate analysis was performed to assess the effect of heparin use. RESULTS: There were 550 AV access cases identified: brachiocephalic (37.5%), brachiobasilic (29.3%), and radiocephalic fistulas (12.9%), and AV grafts (16.9%). Average patient age was 62.6 years and 58.9% were male. Full heparinization was used in 21.3%, partial heparinization in 58.7%, and no heparin was used in 20% of cases. Protamine was used in 94.9% of full heparin cases and 51.4% of partial heparin cases. No perioperative arterial thrombosis or distal embolism was observed. Perioperative wound hematoma rate was 3.4%, 3.1%, and 0.9% in full heparin, partial heparin, and no heparin cohorts, respectively (P = 0.42). Early loss of primary patency was 11.1%, 7.7%, and 6.4% for full heparin, partial heparin, and no heparin cases, respectively (P = 0.39). There were no differences in return to the operating room or perioperative survival. On multivariable analysis, full heparin use (odds ratio [OR] 3.82, 95% confidence interval [CI] 0.41-35.9, P = 0.24) and partial heparin (OR 4.03, 95% CI 0.5-32.6, P = 0.19) use were not significantly different from no heparin cases with respect to 30-day perioperative hematoma rate. Full heparin (OR 1.76, 95% CI 0.65-4.78, P = 0.26) and partial heparin (OR 1.13, 95% CI 0.46-2.75, P = 0.79) were not significantly different from no heparin cases with respect to early loss of primary patency. CONCLUSIONS: Intraoperative heparin use, at full or partial doses, did not affect perioperative outcomes after AV access creation. Overall complication event rate was low for all groups. AV access can be safely performed without intraoperative heparin use.

Carotid Endarterectomy Performed before the Weekend is Associated with Increased Length of Stay.

OBJECTIVE: Length of stay (LOS) is commonly used to gauge hospital resource utilization and can affect hospital profit margin. Other fields of surgery have showed that operations performed close to the weekend have longer LOS and higher patient morbidity. Our goal was to investigate whether asymptomatic patients undergoing elective carotid endarterectomy (CEA) earlier in the week had a shorter LOS and improved clinical outcomes compared to those treated before the weekend. METHODS: The Vascular Quality Initiative database was queried for elective weekday CEAs performed for asymptomatic carotid stenosis from 2005 to 2017. Univariate and multivariate analyses were completed to compare outcomes based on the day of the week. RESULTS: There were 26,882 asymptomatic CEAs performed on Monday (20.3%), Tuesday (23.0%), Wednesday (21.3%), Thursday (18.8%), and Friday (16.6%). The mean patient age was 70.5 years, and 59.2% were male. Thirty-day mortality (0.4%) and perioperative complications including stroke (1.4%), myocardial infarction (0.7%), and return to the operating room (1.5%) were not significantly different across weekdays. Patients were discharged on statins in 84.2% of cases and aspirin in 91.5% of cases. The mean LOS ranged from 1.6 ± 2.2 days to 1.8 ± 3.2 days. CEAs performed on Fridays had a longer LOS (1.8 ± 2.4; P < 0.001). Multivariate analysis demonstrated that CEAs performed on Friday had longer LOS compared to those performed on Monday through Thursday (means ratio: 1.05, 95% confidence interval [CI]: 1.03-1.07; P < 0.001). However, there were no differences in perioperative complications to attribute this to. Friday CEA did not have an effect on discharge medication compliance with aspirin (odds ratio: 0.94, 95% CI: 0.82-1.07; P = 0.339) or statin medications (odds ratio: 0.90, 95% CI: 0.79-1.03; P = 0.126). CONCLUSION: Asymptomatic CEA performed before the weekend was associated with longer LOS although there were no differences in perioperative mortality, morbidity, and discharge medication compliance. Such LOS increase, albeit small, may affect the hospital profit margin for the procedure and performing an elective CEA on asymptomatic patients earlier in the week may benefit in a shorter LOS. Improved team staffing and resources on weekends are potential areas for improvement for earlier discharge; however, further investigation is needed.